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r <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: « I CONSTRUCTION <br /> Premise Address: D S P o Cl, Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> I< Bentonite (from) (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type tit 17F-7 — <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company Vr'k <br /> Driller: '�^ / nf <br /> casing <br /> height <br /> ConsultantI — —qVT <br /> �tf <br /> Geologist , I ABOVE-GACUND C-�q;Ty.Box <br /> COMPLETION CCMPLETICN <br /> SPECIAL PERMIT INFO. 'rte G=nd S —� <br /> prcvt <br /> Distance to sewer line _S__� <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - ft. <br /> tt. _ <br /> O <br /> C <br /> SAMPLING ilonad <br /> soc cn <br /> Holding Temperature = VI"Pa�k <br /> Method rd <br /> • Screening Method _ <br /> Tracking Sheet - (y/ n) <br /> tt. = ti. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENI <br /> Contamination Noted - (y/ n) <br /> Storage Location Blankg ripe $ Screen —K• <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravcl <br /> Mix Ratios Filter Pack type/size <br /> M <br /> installation Ration Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n) <br /> Type of nethod <br /> EH 2?29 <br />